HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 BARCO LANE 1/2/2024 1110111
Commonwealth of Massachusetts
Ila City/Town of ANO **K)1(-
System Pumping Record
y'M- Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, Z G C, L/L3/tie
use only the tab 1
key to move your Address _
cursor-do not �/p►'Jh 1}f�J�(/(✓°1/ �c t,� Of$L(S
use the return City/Town State Zip Code
key.
2. System
�Owner: \ , p
Name
nlno
Address(if different from location)
City/Town State Zip z Code
r 1 1 -
Telephone u� member
B. Pumping Record D
1. Date of Pumping Date l 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
6. Sy5?.rn Pumped By:
Jam_ e_ �, �rc� lJ(na 1 -z t_�
Name - Vehicle License Number
jy10���(f ,�i tV Say, /w"►�► ! webA��y
Company J
7. Location where coptqints were disposed:
Signature 161f H j1er Date
Signature of Recility(or at facility receipt) Date
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